He blames his addiction. He started using in middle school, and by the time he was an adult he was addicted to meth and heroin. At various points, he’s done time alongside his mom, his dad, his sister, and his younger brother.

“That’s all I’ve known my whole life,” said Clark, 31, in December.

Clark was at the jail to pick up his sister, who had just been released. The siblings think this time will be different. They are both sober. Shantel Clark, 33, finished earning her high school diploma during her four-month stay at the jail. They have a place to live where no one is using drugs.

And they have Cheryl Swapp, the county sheriff’s new community health worker, on their side.

“She saved my life probably, for sure,” Garrett Clark said.

Swapp meets with every person booked into the county jail soon after they arrive and helps them create a plan for the day they get out.

She makes sure everyone has a state ID card, a birth certificate, and a Social Security card so they can qualify for government benefits, apply to jobs, and get to treatment and probation appointments. She helps nearly everyone enroll in Medicaid and apply for housing benefits and food stamps. If they need medication to stay off drugs, she lines that up. If they need a place to stay, she finds them a bed.

Then Swapp coordinates with the jail captain to have people released directly to the treatment facility. Nobody leaves the jail without a ride and a drawstring backpack filled with items like toothpaste, a blanket, and a personalized list of job openings.

“A missing puzzle piece,” Sgt. Gretchen Nunley, who runs educational and addiction recovery programming for the jail, called Swapp.

Swapp also assesses the addiction history of everyone held by the county. More than half arrive at the jail addicted to something.

Nationally, booked into local jails struggle with a substance use disorder — at least six times the rate of the general population, according to the federal Substance Abuse and Mental Health Services Administration. The incidence of mental illness in jails is more than twice the rate in the general population, federal data shows. At least 4.9 million people are arrested and jailed every year, according to an by the Prison Policy Initiative, a nonprofit organization that documents the harm of mass incarceration. Of those incarcerated, 25% are booked two or more times, the analysis found. And among those arrested twice, more than half had a substance use disorder and a quarter had a mental illness.

“We don’t lock people up for being diabetic or epileptic,” said David Mahoney, a retired sheriff in Dane County, Wisconsin, who served as president of the in 2020-21. “The question every community needs to ask is: ‘Are we doing our responsibility to each other for locking people up for a diagnosed medical condition?’”

The idea that county sheriffs might owe it to society to offer medical and mental health treatment to people in their jails is part of a broader shift in thinking among law enforcement officials that Mahoney said he has observed during the past decade.

“Don’t we have a moral and ethical responsibility as community members to address the reasons people are coming into the criminal justice system?” asked Mahoney, who has 41 years of experience in law enforcement.

Swapp previously worked as a teacher’s aide for those she calls the “behavior kids” — children who had trouble self-regulating in class. She feels her work at the jail is a way to change things for the parents of those kids. And it appears to be working.

Since the Sanpete County Sheriff’s Office hired Swapp last year, recidivism has dropped sharply. In the 18 months before she began her work, 599 of the people booked into Sanpete County Jail had been there before. In the 18 months after she started, that number dropped to 237.

In most places, people are released from county jails with no health care coverage, no job, nowhere to live, and no plan to stay off drugs or treat their mental illness. that people newly released from incarceration face a risk of overdose that is 10 times as high as that of the general public.

Sanpete wasn’t any different.

“For seven to eight years of me being here, we’d just release people and cross our fingers,” said Jared Hill, the clinical director for Sanpete County and a counselor at the jail.

Nunley, the programming sergeant, remembers watching people released from jail walk the mile to town with nothing but the clothes they’d worn on the day they were arrested — it was known as the “walk of shame.” Swapp hates that phrase. She said no one has made the trip on foot since she started in July 2022.

Swapp’s work was initially funded by a grant from the U.S. Health Resources and Services Administration, but it has proved so popular that commissioners in Sanpete County voted to use a portion of its to cover the position in the future.

Swapp doesn’t have formal medical or social work training. She is certified by the state of Utah as a community health worker, a job that has become more common nationwide. There were about 67,000 people working as community health workers in 2022, according to the .

Evidence is mounting that the model of training people to help their neighbors connect to government and health care services is sound, said Aditi Vasan, a senior fellow at the Leonard Davis Institute of Health Economics at the University of Pennsylvania who has on the relatively new role.

The day before Swapp coordinated Shantel Clark’s release, she sat with Robert Draper, a man in his 50s with long white hair and bright-blue eyes. Draper has been in and out of jail for decades. He was sober for a year and had been taking care of his ill mother. She kept getting worse. Then his daughter and her child came to help. It was all a little too much.

“I thought, if I can just go and get high, I can deal with this shit,” said Draper. “But after you’ve been using for 40 years, it’s kinda easy to slip back in.”

He didn’t blame his probation officer for throwing him back in jail when he tested positive for drugs, he said. But he thinks jail time is an overreaction to a relapse. Draper sent a note to Swapp through the jail staff asking to see her. He was hoping she could help him get out so he could be with his mom, who had just been sent to hospice. He had missed his father’s death years ago because he was in jail at the time.

Swapp listened to Draper’s story without interruptions or questions. Then she asked if she could run through her list with him so she would know what he needed.

“Do you have your Social Security card?”

“My card?” Draper shrugged. “I know my number.”

“Your birth certificate, you have it?”

“Yeah, I don’t know where it is.”

“Driver’s license?”

“No.”

“Was it revoked?”

“A long, long time ago,” Draper said. “DUI from 22 years ago. Paid for and everything.”

“Are you interested in getting it back?”

“Yeah!”

Swapp has some version of this conversation with every person she meets in the jail. She also runs through their history of addiction and asks them what they most need to get back on their feet.

She told Draper she would try to get him into intensive outpatient therapy. That would involve four to five classes a week and a lot of driving. He’d need his license back. She didn’t make promises but said she would talk to his probation officer and the judge. He sighed and thanked her.

“I’m your biggest fan here,” Swapp said. “I want you to succeed. I want you to be with your mom, too.”

The federal grant that funded the launch of Sanpete’s community health worker program is held by the regional health care services organization Intermountain Health. Intermountain took the idea to the county and has provided Swapp with support and training. Intermountain staff also administer the $1 million, three-year grant, which includes efforts to increase addiction recovery services in the area.

A similarly funded program in Kentucky called First Day Forward took the community health worker model a step further, using “peer support specialists” — people who have experienced the issues they are trying to help others navigate. Spokespeople from HRSA pointed to four programs, including the ones in Utah and Kentucky, that are using their grant money for people facing or serving time in local jails.

Back in Utah, Sanpete’s new jail captain, Jeff Nielsen, said people in small-town law enforcement weren’t so far removed from those serving time.

“We know these people,” Nielsen said. He has known Robert Draper since middle school. “They are friends, neighbors, sometimes family. We’d rather help than lock them up and throw away the key. We’d rather help give them a good life.”

Ä¢¹½Ó°Ôº Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Ä¢¹½Ó°Ôºâ€”an independent source of health policy research, polling, and journalism. Learn more about .

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The deal comes a month after the administration unexpectedly rejected sweeping heat standards for workers in sweltering warehouses, steamy kitchens, and other dangerously hot job sites. The rules had been years in the making, and a state worker safety board voted to adopt them March 21. But in a controversial move, the administration upended the process by saying the cost to cool state prisons was unclear — and likely very expensive.

So the Democratic administration said the rules can proceed but must exempt tens of thousands of workers at 33 state prisons, conservation camps, and local jails, “in recognition of the unique implementation challenges,” said Eric Berg, of California’s Division of Occupational Safety and Health, at a Thursday hearing. A separate regulation will be drafted for correctional facilities, which could take a year, if not longer.

It’s unclear if the standards will become law in time to protect millions of other workers from summer’s intensifying heat. The compromise rules must go through a 15-day public comment period, and legal reviews within 100 days, which could push implementation well into summer. But that can’t even happen until the original regulation is rejected by the Office of Administrative Law, which has until next month.

“Summer is arriving, and many workers, unfortunately, are going to suffer heat conditions,” said , legal director at the Warehouse Worker Resource Center. “Some will likely get really sick, potentially even die from heat illness, while we continue to wait for the standard.”

Berg told members of the Occupational Safety and Health Standards Board on April 18 that Cal/OSHA would try to accelerate the timeline and get protections in place for summer.

California has had heat standards on the books for outdoor workers , and rules for indoor workplaces have been in the works since 2016. The proposed standards would require work sites to be cooled below 87 degrees Fahrenheit when employees are present and below 82 degrees in places where workers wear protective clothing or are exposed to radiant heat, such as furnaces. Buildings could be cooled with air conditioning, fans, misters, and other methods.

The rules allow workarounds for businesses that can’t cool their workplaces sufficiently, such as laundries or restaurant kitchens.

Because the rules would have a sweeping economic impact, state law requires Newsom’s Department of Finance to sign off on the financial projections, which it refused to do last month when it was unclear how much the regulations would cost state prisons. The California Department of Corrections and Rehabilitation said implementing the standards in its prisons and other facilities could cost billions, but the pegged the cost at less than $1 million a year.

Department of Finance spokesperson H.D. Palmer couldn’t promise that the compromise rules would be signed off on, but “given that the earlier correctional estimates were the issue before, not having them in the revised package would appear to address that issue,” he said.

Business and agricultural groups complained repeatedly during the rulemaking process that complying with the rules would burden businesses financially. At the April 18 hearing, they highlighted the administration’s lack of transparency and questioned why one sector should be given an exemption over another.

“The massive state costs that are of concern, specifically around prisons in the billions of dollars, are also costs that California employers will bear,” said Robert Moutrie, a senior policy advocate at the California Chamber of Commerce.

Labor advocates asked board members not to exempt prisons, saying corrections workers need protection from heat, too.

“It’s a huge concern that prison workplaces all over are being excluded from the heat standard, leaving out not just guards, but also nurses, janitors, and the other prison workers across California unprotected from heat,” said AnaStacia Nicol Wright, an attorney with Worksafe, a workplace safety advocacy nonprofit. “California needs to prioritize the safety and well-being of their workers, regardless of whether they work in corrections, a farm, or a sugar refinery.”

Prisons will continue to provide cooling stations in air-conditioned areas, and make water stations, fans, portable cooling units, and ice more available to workers, according to the California Department of Corrections and Rehabilitation. Prison housing units, which house roughly as of April 17, all can be cooled, usually with evaporative coolers and fans. The department has 58,135 staff members, spokesperson Terri Hardy said.

Only have adopted heat rules for indoor workers. Legislation has , and even though the Biden administration has initiated the long process of establishing national heat standards for outdoor and indoor work, they may take years to finalize.

in California from indoor heat between 2010 and 2017. Heat stress can lead to heat exhaustion, heatstroke, cardiac arrest, and kidney failure. In 2021, the Centers for Disease Control and Prevention reported, occurred nationally, which is likely an undercount because health care providers are not required to report them. It’s not clear how many of these deaths are related to work, either indoors or outdoors.

“These are not overly cumbersome things to implement, and they are easy ways to keep people safe and healthy,” said Jessica Early, patient advocacy coordinator at the National Union of Healthcare Workers. “Now is the urgent time to make our workplaces safer and more resilient in the face of rising temperatures.”

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U.S. District Judge Claudia Wilken’s rulings on March 20 centered on the prison system’s need to help deaf, blind, and low-vision prisoners better prepare for parole hearings, though the decisions are also likely to improve accommodations for hundreds of other prisoners with those disabilities.

“I believe I should have the same opportunity as hearing individuals,” a prisoner, deaf since birth, said in court documents.

The lawsuit is one of several class-action proceedings that have led the courts to assume oversight of the prison system’s treatment of those who are sick or suffer from mental illnesses.

“It is difficult not to despair,” a blind prisoner said in written testimony. “I am desperate for some kind of assistance that will let me prepare adequately for my parole hearing.”

The parole process can begin more than a year before an incarcerated person’s hearing and last long afterward. And the consequences of rejection are great: People denied parole typically must wait three to 15 years before they can try again.

Prisoners are expected to review their prison records and a psychologist’s assessment of whether they are at risk for future violence, write a release plan including housing and work plans, write letters of remorse, and prepare a statement to parole officials on why they should be released.

“It is a very time-consuming and important process,” said Gay Grunfeld, one of the attorneys representing about 10,000 prisoners with many different disabilities in the federal class-action lawsuit. “All of these tasks are harder if you are blind, low-vision, or deaf.”

The California Department of Corrections and Rehabilitation and its Board of Parole Hearings “remain committed to conducting fair hearings and ensuring access to the hearings for all participants. We are assessing the potential impact of the order and exploring available legal options,” said spokesperson Albert Lundeen.

The department counts more than 500 prisoners with serious vision problems and about 80 with severe hearing problems, though Grunfeld thinks both are undercounts.

California’s prison system has lagged in adopting technological accommodations that are commonly used in the outside world, Wilken found in .

For instance, California gives prisoners that can be used for communications and entertainment, and since late 2021 has gradually been providing secure laptops to prisoners who are enrolled in college, GED, and high school diploma programs.

But officials balked at providing computers that Wilken decided are needed by some prisoners with disabilities. She required the department to develop a plan within 60 days of to, among many things, provide those individuals with laptops equipped with accommodations like screen magnification and software that can translate text to speech or Braille.

“It would make a huge difference to me to have equipment that would let me listen to and dictate written words, or produce written documents in another accessible manner,” testified the blind prisoner. He added that such accommodations “would finally let me properly prepare for my parole hearing with the privacy, independence, and dignity that all humans deserve.”

Similarly, California routinely uses video cameras during parole proceedings, including when it conducted hearings remotely during the coronavirus pandemic. But prison policy has prohibited videotaping the hearings, including sign language translations that some deaf prisoners rely on to understand the proceedings.

The deaf-since-birth prisoner, for example, testified that he also doesn’t speak, his primary method of communication is American Sign Language, and his English is so poor that written transcripts do him no good. He advocated for recorded sign language translations of the hearings and related documents that he could review whenever he wanted, in the same way that other inmates can review written text.

Wilken ordered prison officials to comply.

“They need to be able to watch it later, not read it later,” said Grunfeld. “It’s going to make a huge difference in the lives of deaf signers.”

The department recently acquired 100 portable electronic video magnifiers, at a cost of $1,100 each, that prisoners with low vision can check out to use in their cells. The technology will augment similar devices in prison libraries that prisoners say aren’t private and can be used only during libraries’ limited hours.

Wilken said officials acquired the magnifiers only after prodding by prisoners and their attorneys.

Grunfeld said the judge’s detailed order, which includes requirements like better assistance from attorneys, will “make sure that people with disabilities are on an equal footing as people who don’t have disabilities.”

“My colleagues and I have been working for several years to persuade CDCR to adopt this technology, and it’s been slow-going. But they’ve gradually accepted that they do need to do this,” Grunfeld said. “It’s long past due, but at least it’s coming.”

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But corrections officials won’t disclose basic details of the now-stalled study — even the cost to taxpayers for two consulting firms and more than two dozen national experts retained to examine the issue in 2023. State lawyers cited attorney-client privilege and ongoing litigation in denying Ä¢¹½Ó°Ôº Health News’ public records requests for the information. Independent legal experts questioned the blanket denials.

The legal saga began in 1990, when attorneys representing prisoners sued California for violating the U.S. Constitution’s ban on cruel and unusual punishment by providing inadequate mental health care in prisons.

The court ruled against the state in 1995, and since then a federal judge, guided by a court-appointed special master, oversees the state’s treatment of about 31,000 prisoners with serious mental illness. It’s one of several major federal lawsuits that have largely stripped the state of control of its own prison system.

California officials set out nearly four years ago to show that care has improved beyond the constitutional threshold, retaining Colorado-based Voorhis/Robertson Justice Services and Chicago-based Falcon Correctional and Community Services to undertake a study. In August 2022, their analysts reported that the state’s treatment guidelines and its required levels of staffing exceed national standards “and exceed the levels needed for providing clinically adequate care for patients in a correctional setting.”

The state then retained the same firms to conduct “a broader, systemwide study” of mental health services in California prisons and how they compare to national standards and other similar systems.

California could seek to end or modify court supervision based on the experts’ findings and recommendations, though they “have not made any decision to move for termination,” Paul Mello, one of the attorneys representing the state, said in a letter in court documents.

“They’re being cagey about exactly what the purpose is, but they’re reserving the right to use it to terminate,” said Michael Bien, an attorney representing the rights of prisoners with mental illness in the case.

Despite the potential significance of the study, corrections officials repeatedly declined to provide even basic details about it.

They initially denied that it was their contract at all, pointing to a different state agency. A week later, and after Ä¢¹½Ó°Ôº Health News’ further inquiries, corrections officials acknowledged it was indeed their contract. But they denied Ä¢¹½Ó°Ôº Health News’ repeated public records requests for the contracts, the costs, or the expense invoices filed by the consultants, citing attorney-client privilege, attorneys’ confidential work product, and the ongoing litigation.

Brittney Barsotti, general counsel of the California News Publishers Association, said the state could have kept sensitive information confidential while still responding to other aspects of the records request.

“The courts have held time and time again that redaction of documents is preferred over blanket denials like this,” she said. The use of blanket denials without any context or explanation is “an ongoing and I’d say even expanding issue,” she said in advance of , a collaborative effort to emphasize the importance of public records and open government, observed this year March 10-16.

Without information on how exemptions to public records laws apply to specific documents, it is difficult for reporters or other members of the public to challenge such denials or tailor their requests, Barsotti added.

“They should be able to provide some figures on cost,” she added. “They should at least be able to provide aggregate general information that shouldn’t come under these various exemptions.”

The California Public Records Act allows exemptions for documents prepared specifically for use in pending litigation, said David Loy, legal director of the nonprofit, nonpartisan First Amendment Coalition, which supports government transparency. And says government contracts, “including the price and terms of payment,” are generally public records, while listing the same legal exemptions.

In their latest denial, on March 11, department officials cited a prior court ruling that legal privacy covers invoices, including the aggregate cost.

In court documents, however, the state’s lawyers deny that the study is specifically tied to the litigation but is part of their self-evaluation of mental health care, casting doubt on the rationale given for denying the records requests.

Corrections officials provided Ä¢¹½Ó°Ôº Health News with a single, two-page August 2020 letter to the consultants outlining the hourly rates the state would pay for the initial 18-month study. Managing partners or principals in the consulting firms were to receive $350 an hour; technical experts, $300; associates, $200; and support staff, $120. In addition, California agreed to reimburse the consultants for such expenses as airfare, lodging, meals, car rental, and gas.

Although the state declined to provide any records related to the bigger subsequent study, court documents outline the sweeping, exhaustive nature of what was anticipated.

One hired consultant, Elizabeth Falcon, the founder of Falcon, said in a written declaration that the research involved was a “massive logistical undertaking.” The consulting firms hired about 30 top specialists in behavioral health, psychiatry, security, operations, nursing, programming, staffing, and data analytics, she said. They spent eight months developing a scientifically validated method to study the mental health care at prisons.

Prisoners’ attorneys have objected that the state’s plan for extensive visits to all 28 prisons where mental health care is provided is overly burdensome for patients and attorneys, as well as expensive.

The consultants had completed partial tours of five prisons in July 2023 before Chief U.S. District Judge Kimberly Mueller temporarily halted the visits while she considered their scope.

Mueller rejected the state’s request to resume the tours in a March 6 order.

“The record is devoid of several pieces of threshold evidence necessary to support the costly and time-consuming prison tours,” she wrote in part. Those include evidence backing the initial study’s finding that California’s standards exceed national standards or that those national standards themselves are sufficient.

Moreover, the tours would distract from the state’s ongoing and, so far, deficient efforts to bring mental health care to constitutionally adequate levels, she wrote. They also would be redundant to ongoing reviews by the special master, she wrote, including his expert’s findings that the state still is not doing enough to .

Department officials are reviewing the order, said spokesperson Terri Hardy, who, because of the ongoing lawsuit, would not say whether they will appeal Mueller’s decision.

Gov. Gavin Newsom is the second consecutive Democratic governor to toy with ending the litigation. His predecessor, Jerry Brown, tried unsuccessfully more than a decade ago, citing similar findings by the state’s experts, but then-U.S. District Judge Lawrence Karlton that the state was still providing substandard care.

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SACRAMENTO, Calif. — California could face more than $40 million in fines after it failed to improve suicide prevention measures in state prisons despite a federal judge’s warning that she would impose financial penalties for each violation.

Chief U.S. District Judge Kimberly Mueller told state officials over a year ago that she would start imposing fines unless they implemented 15 suicide prevention protocols that had been lacking for nearly a decade.

But court expert Lindsay Hayes reported March 1 that the state continues to lag on 14 of the 15 safeguards. The state even regressed in such areas as failing to house prisoners in suicide-resistant cells when they are first placed in segregation, often including solitary confinement, in which prisoners are particularly vulnerable. The special cells lack hooks, wire grates, or other protrusions from which prisoners can hang themselves, for instance.

Suicides have long been a problem in California prisons and are considered a bellwether of a broader, decades-long lack of adequate prison mental health care. They are one of several ongoing issues at the center of a class-action federal lawsuit that dates to 1990.

“Mr. Hayes’ finding of backsliding with respect to some of the remaining recommendations is deeply concerning, particularly in light of the nine years that have passed since he initially offered these recommendations,” wrote Matthew Lopes Jr., the special master retained by Mueller to help oversee prison mental health care.

California Department of Corrections and Rehabilitation spokesperson Pedro Calderón Michel said officials are reviewing the report and will file a formal response April 2. He said the department has a robust suicide prevention program, which has expanded since 2020. A team of psychologists follows a guidebook on suicide prevention practices modeled after the monitoring done by the special master’s own experts. Additionally, that team provides real-time feedback, and the department reviews each suicide.

“The health and well-being of every person in our care are of the utmost importance,” Calderón Michel said.

And as the state continues to experience a shortage of mental health care providers, he said, the department has taken steps to expand the use of telepsychiatry, as well as increasing salaries and benefits to attract more workers.

Thirty California state prisoners died by suicide last year. That’s an increase from 20 suicides in 2022 and 15 in 2021 but fewer than in the . California’s rate of 32 suicides per 100,000 prisoners in 2023 exceeded the most recently available national state prison rate of 27 per 100,000.

Hayes’ report included eight instances in which prisoners’ bodies were not discovered until rigor mortis had set in, a stiffening of the joints and muscles that occurs several hours after death. Some of those prisoners were supposed to be monitored regularly to make sure they did not harm themselves; the delay in discovering their deaths cast doubt on whether they were being checked adequately.

In another case, a prisoner was supposed to be under constant suicide watch after he twice tried to kill himself the same day that he sent farewell notes to family members. Yet he was allowed to keep his tennis shoes against the chief psychiatrist’s orders, and he was placed unmonitored in a standard cell instead of a suicide-resistant cell.

An hour later, he was found hanging from the upper bunk by a shoestring.

“You realize this is not a game, these are human beings,” said Michael Bien, an attorney representing prisoners in the lawsuit. “Certainly, you shouldn’t be making the same mistakes that are preventable and foreseeable again and again and again.”

Mueller said she would impose $1,000 daily fines starting April 1, 2023, for each unmet safeguard at each prison that failed to comply. The protocols include such things as suicide prevention training and treatment planning, suicide risk evaluations, using suicide-resistant cells, and checking on susceptible prisoners every 30 minutes.

Hayes and Lopes did not say in their court filings how many fines accumulated. But their court filings contain identical charts outlining how many prisons still failed to meet each of the 15 standards during Hayes’ recent inspections. They tally 124 areas of ongoing noncompliance carrying $1,000 daily fines.

If Mueller levied fines for the 11 months between last April and when Hayes filed his report, they would top $41.5 million. But her order has the daily fines continuing indefinitely, and other variables might affect the total.

“No matter how you calculate it, it’s still going to be a very substantial number,” Bien said.

If Mueller follows previous practice, she will next hold a hearing on Hayes’ report and the pending fines. She has not said what the fines would be used for, but the goal is to encourage a resolution of the ongoing problems, not to punish the state.

Hayes’ report comes as Mueller is already considering collecting fines topping $95 million for state officials’ yearlong failure to hire enough mental health professionals to provide adequate treatment in state prisons.

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Ä¢¹½Ó°Ôº Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Ä¢¹½Ó°Ôºâ€”an independent source of health policy research, polling, and journalism. Learn more about .

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Occupational Therapists Change Lives. CMS Must Better Support Them.

Occupational therapists are critical in helping patients adjust to new circumstances, empowering them with the tools they need to overcome barriers and regain control over their lives. Whether you’re transitioning from homelessness into a home (“In Los Angeles, Occupational Therapists Tapped to Help Homeless Stay Housed,” Jan. 24) or relearning how to do everyday tasks following a stroke, OTs are key to patients’ care plan.

But the critical care provided by OTs is being threatened by another year of payment cuts imposed by Medicare, our nation’s health care program for people age 65 and up. Many older patients treated by OTs access insurance coverage through Medicare, which typically reimburses providers at a lower rate than private insurers. And now, with payment cuts that went into effect on Jan. 1 — despite warnings and backlash from lawmakers, patients, and providers — OTs are struggling to deliver care with lower Medicare payment.

Investing in occupational therapy improves health outcomes for patients, has the potential to reduce the burden on hospitals and other health care clinicians, and keeps individuals healthy and independent. Medicare’s payment cuts only compromise the ability of providers to deliver comprehensive, compassionate care. Medicare must recognize the long-term patient benefits occupational therapy has to offer.

Luckily, Congress is considering a bill that would reverse these harmful payment cuts. The Preserving Seniors’ Access to Physicians Act of 2023 (HR 6683), would reverse the cuts that went into effect on Jan. 1, alleviating financial stress for occupational therapists and preserving patient access. I strongly urge lawmakers to prioritize and protect occupational therapy services and immediately pass HR 6683 for America’s Medicare patients.

— Doug Fosco, an occupational therapist practicing at Two Trees Physical Therapy in Ventura, California

An assistant professor at Ontario’s Western University weighed in on X.

Great to see the role of with persons who experience profiled in . Thanks for your work in LA with and . Check it out !

— Carrie Anne Marshall, PhD (@cannemarshall)

— Carrie Anne Marshall, Sydenham, Ontario

Congress Must Finish the Job on Site-Neutral Payments

There’s an obvious solution to rein in government spending and patient out-of-pocket costs: Pay identical prices for identical care (“In Fight Over Medicare Payments, the Hospital Lobby Shows Its Strength,” Feb. 13).

As a community oncologist, it is clear to me how Medicare favors hospitals by paying more for services provided in hospital outpatient departments (HOPDs) than the same care delivered in community-based facilities. For example, last year, Medicare paid over as much in an HOPD as in a free-standing office for drug administration services. It’s not just Medicare paying too much; patients also face higher out-of-pocket costs for care provided in HOPDs. If the is signed into law, cancer patients would immediately pay less for treatments like chemotherapy.

One unintended consequence of current payment disparities is consolidation. To leverage higher reimbursements, health systems scoop up independent practices — a growing problem that is particularly pronounced in oncology. , 435 community cancer clinics closed, while 722 contracted with or were acquired by hospitals. This consolidation is reducing patient access, particularly in rural areas, where many independent clinics operate small satellite sites that tend to be the first to close when hospitals acquire a community-based practice.

It’s time for Congress to finish the job through bills like the Lower Costs, More Transparency Act and the , which would help level the playing field once and for all.

— Scott Rushing, Vancouver, Washington

The chief marketing officer of SKYGEN cut to the chase on X.

In the battle to control healthcare costs, hospitals are deploying their political power to protect their bottom lines.

— Donald H. Polite (@DonaldPolite)

— Donald H. Polite, Milwaukee

The ‘Gold Card’ Shuffle

Prior authorization, by definition, creates delays in care and bureaucratic barriers for physicians — which is why it is so troubling that many insurers now require prior authorization for large categories of procedures with no evidence of overuse or inappropriate use. With health insurers increasingly implementing questionable prior authorization policies, state and federal lawmakers are racing to erect safeguards that ensure patients’ access to timely care (“States Target Health Insurers’ ‘Prior Authorization’ Red Tape,” Feb. 12).

Much of the legislation to address this growing problem centers around the use of “Gold Cards” that exempt providers whose previous requests for prior authorization have been approved for a certain period. In general, these laws are important for patients who can’t afford to wait for care — especially in the field of gastroenterology where severe abdominal pain or blood in the stool could indicate a serious condition like cancer.

However, some insurance companies are co-opting the “Gold Card” term to justify new prior authorization requirements instead of streamlining existing ones. Consider the case of UnitedHealthcare, which announced it would roll out a “Gold Card” prior authorization program this year for most colonoscopies and endoscopies. No other insurer has levied such a policy, nor does the research suggest there is an overutilization of these vital services. Despite nearly a year of good faith efforts to seek transparency and guidance from UHC, the company has failed to release any data or justification that these services are improperly utilized.

If anything, diagnostic and surveillance colonoscopies and endoscopies may be underutilized. New research from the American Cancer Society shows an alarming spike in the number of younger Americans being diagnosed with and dying from colorectal cancer. Since symptoms of colorectal cancer don’t often appear until the disease is at a more advanced stage, early detection is key. Any disruption to surveillance colonoscopies (which follow removal of a precancerous polyp and are part of the screening continuum) caused by UHC’s forthcoming prior authorization policy would be dangerous for the company’s 27 million commercial beneficiaries.

The American Gastroenterological Association strongly urges UHC to rescind its “Gold Card” prior authorization policy. Policymakers must monitor how insurers are co-opting concepts meant to protect patients, in particular UHC’s faux “Gold Card,” which threatens patient access to a procedure proven to save lives.

— Barbara Jung, president of the American Gastroenterological Association, Seattle

In an X post, a senior fellow at the Manhattan Institute pointed out the value in requiring prior authorization.

Case-by-case prior authorization is never fun, but surely preferable to most other methods of eliminating needless spending (ex post denials of reimbursement, higher cost-sharing, capped global budgets, etc…)

— Chris Pope (@CPopeHC)

— Chris Pope, a senior fellow at the Manhattan Institute, New York City

Hospice in Prison: A Transformative View

I was so impressed with Markian Hawryluk’s exceptionally well-written article “Death and Redemption in an American Prison” (Feb. 21). I was privileged to serve as an inaugural member of the American Hospital Association’s Circle of Life Award committee, from 1999 to 2004. The awards were established to recognize the most outstanding hospice and palliative care programs in the U.S. The very first year, we received an application from the country’s largest maximum-security prison in Angola, Louisiana, the subject of Mr. Hawryluk’s wonderful article. The prison was one of the five finalists chosen for a site visit in 2000. I volunteered to be on team to visit and evaluate the prison’s hospice services.

Twenty-four years later, I still remember my conversation with one of the inmate volunteers who had just returned from bathing and feeding a dying prisoner. He told me the inmate said, “I love you.” Then the inmate volunteer stated, “I never heard those words before — not from my father, who I never met, nor from my mother.” In 2000, if one were sentenced to life at the Louisiana State Penitentiary, there was no chance for parole. When we met with the warden, he mentioned there was a waiting list of prisoners who wanted to be hospice volunteers.

Please convey my deep appreciation to Mr. Hawryluk for his outstanding article.

— Paul Hofmann, president of the Hofmann Healthcare Group, Moraga, California

A digital storyteller shared the article on X.

Your one, long read for today – it's beautifully and thoughtfully written and reported"Sometimes when you're in a dark place, you find out who you really are and what you wish you could be," Steven Garner said. "Even in darkness, I could be a light."

— Ameera B. ا ميرة بت 🪬 (@meerabee)

— Ameera Butt, Los Angeles

Feeling Insecure Because of Social Security Tactics

When will you continue your series on the overpayments to the Social Security Administration (“Overpayment Outrage”)? People are still suffering without benefits because the agency says people were overpaid and wants the money back. Why is nobody else asking more questions?

People in this country worked hard and paid taxes. And when it is time to retire, the Social Security Administration refuses to pay if, all of a sudden, it discovers you have been overpaid. They have told me I owe them $30,000 from over 20 years ago, and I do not know what they are talking about, but they want to take my retirement money until it’s paid off. Or they want you to say it is OK to take a percentage out. Doing that would say you’re guilty and you owe the money — to me, that’s blackmail.

New immigrants get free phones, medical care, debit cards, food assistance, schooling … that comes to more than my little amount of retirement money. It seems the government can afford to take care of them, but not their own. Everyone who has had their Social Security taken away should be entitled to the free services they get, as we are in the same position — now we have nothing either.

— Thomas Troy, New York City

Lifelong Minnesotan and epidemiologist Eric Weinhandl chimed in on X.

Relatively severe incompetency. Social Security Chief Apologizes to Congress for Misleading Testimony on Overpayments

— Eric Weinhandl (@eric_weinhandl)

— Eric Weinhandl, Victoria, Minnesota

A Balanced View of the Law Curbing Surprise Bills

Ä¢¹½Ó°Ôº Health News’ Elisabeth Rosenthal has long advocated for quality, patient-centric medical care. However, her recent article, “The No Surprises Act Comes with Some Surprises” (Feb. 14), falls short in its analysis of and the federal No Surprises Act (NSA). While she places blame on physicians, the reality is more complicated.

Patients with health insurance should not be burdened with paying more than their normal in-network cost-sharing amount for unexpected out-of-network care. This is not controversial. The legislative debate was never about whether to act on surprise billing, but rather how to act. While insurers favored policies that would allow them to calculate the payment rate medical providers receive, with the NSA, Congress instead chose an approach intended to protect sustainable payment rates that would preserve patients’ access to care. The NSA removes patients from payment disputes between insurers and providers and is intended to encourage negotiations between insurers and providers, with an option for neutral arbitration.

Rosenthal’s article implies a “greedy doctor” narrative, omitting discussion of insurers as contributing to the problems with the NSA’s implementation. While the article notes that many requests for arbitration came from private equity-associated provider organizations, it neglected to note that a single insurance company (UnitedHealthcare) was involved in of arbitration disputes. That is more than the rest of the top five insurance organizations combined. The article also quotes and references papers by Zack Cooper, whose undisclosed connections with UnitedHealthcare came to light through litigation. , UnitedHealthcare not only provided data to Cooper, but helped frame the narrative of the work.

NSA rulemaking has financially incentivized insurers to to unilaterally reduce existing contracted rates and push physicians out-of-network. As for the projected number of requests for arbitration in 2022 (which underestimated “providers’ ire by an order of magnitude”), that projection ignored existing data. In just the first six months of 2021, had more than twice as many arbitration submissions for its state law as the federal government projected for the nation for a full year. More importantly, the article ignores the issue of why doctors request arbitration. Since arbitration is baseball-style and “loser pays,” there is a strong disincentive to request it without a solid reason. In the second quarter of 2023, providers won nearly 80% of disputes, reflecting the fact that doctors are going to arbitration when insurers’ actions are unreasonable.

Further, while it is true that before the NSA too many patients were receiving bills for unexpected out-of-network care, from the Department of Health and Human Services noted that out-of-network billing was actually declining prior to the NSA. Physician suggests that post-NSA out-of-network care is now increasing due to some insurers’ actions.

The bipartisan NSA is a balanced solution to a complicated problem. Difficulties with the law’s implementation, including the volume of dispute submissions and backlog of cases, are due to unintended consequences from rulemaking. Addressing these challenges requires an honest conversation about their cause. Going forward, rulemaking is needed to promote fair network contracting, limit the need for arbitration, and, most importantly, protect patients’ access to care.

— Rich Heller, a pediatric radiologist and the associate chief medical officer for health policy, Radiology Partners, Chicago

Anesthetist-emergency physician-family doctor David Moniz, in an X post, warned of the “unseen consequences” of the No Surprises Act.

Check out the surprising outcomes of the No Surprises Act, designed to protect patients from unexpected medical bills. While it's successfully shielded many patients, there are unseen consequences. Read the full article here: , , …

— David Moniz (@DrDavidMoniz)

— David Moniz, Chilliwack, British Columbia

Ä¢¹½Ó°Ôº Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Ä¢¹½Ó°Ôºâ€”an independent source of health policy research, polling, and journalism. Learn more about .

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Standing in front of the concrete steps of her home in Midway, Texas, Collier, initially barefoot and wearing a baggy gray T-shirt, told officers she planned to see a doctor in the morning because she had been bleeding.

Police body camera footage obtained by Ä¢¹½Ó°Ôº Health News through an open records request shows that the officers then told Collier — who was 29 at the time and enrolled in online classes to study psychology — to turn around.

Instead of taking her to get medical care, they handcuffed and arrested her because she had outstanding warrants in a neighboring county for failing to appear in court to face misdemeanor drug charges three weeks earlier. She had missed that court date, medical records show, because she was at a hospital receiving treatment for pregnancy complications.

Despite her symptoms and being about 13 weeks pregnant, Collier spent the next day and a half in the Walker County Jail, about 80 miles north of Houston. She said her bleeding worsened there and she begged repeatedly for medical attention that she didn’t receive, according to a formal complaint she filed with the Texas Commission on Jail Standards.

“There wasn’t anything I could do,” she said, but “just lay there and be scared and not know what was going to happen.”

Collier’s experience highlights the limited oversight and absence of federal standards for reproductive care for pregnant women in the criminal justice system. Incarcerated people have a constitutional right to health care, yet only a half-dozen states have passed laws guaranteeing access to prenatal or postpartum medical care for people in custody, according to a review of reproductive health care legislation for incarcerated people by a research group at Johns Hopkins School of Medicine. And now abortion restrictions might be putting care further out of reach.

Collier’s arrest was “shocking and disturbing” because officers “blithely” took her to jail despite her miscarriage concerns, said Wanda Bertram, a spokesperson for the Prison Policy Initiative, a nonprofit organization that studies incarceration. Bertram reviewed the body cam footage and Collier’s complaint.

“Police arrest people who are in medical emergencies all the time,” she said. “And they do that regardless of the fact that the jail is often not equipped to care for those people in the way an emergency room might be.”

After a decline during the first year of the pandemic, the number of women in U.S. jails is once again rising, hitting nearly 93,000 in June 2022, a 33% increase over 2020, according to the Department of Justice. Tens of thousands of pregnant women enter U.S. jails each year, by Carolyn Sufrin, an associate professor of gynecology and obstetrics at Johns Hopkins School of Medicine, who researches pregnancy care in jails and prisons.

The health care needs of incarcerated women have “always been an afterthought,” said Dana Sussman, deputy executive director at Pregnancy Justice, an organization that defends women who have been charged with crimes related to their pregnancy, such as substance use. For example, about half of states don’t provide free menstrual products in jails and prisons. “And then the needs of pregnant women are an afterthought beyond that,” Sussman said.

Researchers and advocates worry that confusion over recent abortion restrictions may further complicate the situation. A nurse cited Texas’ abortion laws as one reason Collier didn’t need care, according to her statement to the standards commission.

Texas law allows treatment of miscarriage and ectopic pregnancies, a life-threatening condition in which a fertilized egg implants outside the uterus. However, different interpretations of the law can create confusion.

A nurse told Collier that “hospitals no longer did dilation and curettage,” Collier told the commission. “Since I wasn’t hemorrhaging to the point of completely soaking my pants, there wasn’t anything that could be done for me,” she said.

Collier testified that she saw a nurse only once during her stay in jail, even after she repeatedly asked jail staffers for help. The nurse checked her temperature and blood pressure and told her to put in a formal request for Tylenol. Collier said she completed her miscarriage shortly after being released.

Collier’s case is a “canary in a coal mine” for what is happening in jails; abortion restrictions are “going to have a huge ripple effect on a system already unequipped to handle obstetric emergencies,” Sufrin said.

‘There Are No Consequences’

Jail and prison health policies vary widely around the country and often fall far short of the American College of Obstetricians and Gynecologists’ for incarcerated people. ACOG and other groups recommend that incarcerated women have access to unscheduled or emergency obstetric visits on a 24-hour basis and that on-site health care providers should be better trained to recognize pregnancy problems.

In Alabama, where women have been , the state . But it doesn’t guarantee a minimum standard of prenatal care, such as access to extra food and medical visits, according to Johns Hopkins’ review.

Policies for pregnant women at federal facilities also don’t align with national standards for nutrition, safe housing, and access to medical care, according to a from the Government Accountability Office.

Even when laws exist to ensure that incarcerated pregnant women have access to care, the language is often vague, leaving discretion to jail personnel.

Since 2020, that jails and prisons provide pregnant women “regular prenatal and postpartum care, as necessary.” But last August a woman after seeking medical attention for more than an hour, according to the Montgomery County Sheriff’s Office.

Pregnancy complications can quickly escalate into life-threatening situations, requiring more timely and specialized care than jails can often provide, said Sufrin. And when jails fail to comply with laws on the books, little oversight or enforcement may exist.

In Louisiana, many jails didn’t consistently follow laws that aimed to improve access to reproductive health care, such as providing free menstrual items, according to a May 2023 . The report also said jails weren’t transparent about whether they followed other laws, such as prohibiting the use of solitary confinement for pregnant women.

Krishnaveni Gundu, as co-founder of the Texas Jail Project, which advocates for people held in county jails, has lobbied for more than a decade to strengthen state protections for pregnant incarcerated people.

In 2019, Texas became one of the few states to require that jails’ health policies include obstetrical and gynecological care. The a pregnant person in labor to a hospital, and additional regulations mandate access to medical and mental health care for miscarriages and other pregnancy complications.

But Gundu said lack of oversight and meaningful enforcement mechanisms, along with “apathy” among jail employees, have undermined regulatory protections.

“All those reforms feel futile,” said Gundu, who helped Collier prepare for her testimony. “There are no consequences.”

Before her arrest, Collier had been to the hospital twice that month experiencing pregnancy complications, including a bladder infection, her medical records show. Yet the commission found that Walker County Jail didn’t violate minimum standards. The commission did not consider the police body cam footage or Collier’s personal medical records, which support her assertions of pregnancy complications, according to investigation documents obtained by Ä¢¹½Ó°Ôº Health News via an open records request.

In making its determination, the commission relied mainly on the jail’s medical records, which note that Collier asked for medical attention for a miscarriage once, in the morning on the day she was released, and refused Tylenol.

“Your complaint of no medical care is unfounded,” the commission concluded, “and no further action will be taken.”

Collier’s miscarriage had ended before she entered the jail, argued Lt. Keith DeHart, jail lieutenant for the Walker County Sheriff’s Office. “I believe there was some misunderstanding,” he said.

Brandon Wood, executive director of the commission, wouldn’t comment on Collier’s case but defends the group’s investigation as thorough. Jails “have a duty to ensure that those records are accurate and truthful,” he said. And most Texas jails are complying with heightened standards, he said.

Bertram disagrees, saying the fact that care was denied to someone who was begging for it speaks volumes. “That should tell you something about what these standards are worth,” she said.

Last year, Chiree Harley spent six weeks in a Comal County, Texas, jail shortly after discovering she was pregnant and before she could get prenatal care, she said.

I was “thinking that I was going to be well taken care of,” said Harley, 37, who also struggled with substance use.

Jail officials put her in the infirmary, Harley said, but she saw only a jail doctor and never visited an OB-GYN, even though she had previous pregnancy complications including losing multiple pregnancies at around 21 weeks. This time she had no idea how far along she was.

She said that she started leaking amniotic fluid and having contractions on Nov. 1, but that jail officials waited nearly two days to take her to a hospital. Harley said officers forced her to sign papers releasing her from jail custody while she was having contractions in the hospital. Harley delivered at 23 weeks; the baby boy died less than a day later in her arms.

The whole experience was “very scary,” Harley said. “Afterwards we were all very, very devastated.”

Comal County declined to send Harley’s medical and other records in response to an open records request. Michael Shaunessy, a partner at McGinnis Lochridge who represents Comal County, said in a statement that, “at all times, the Comal County Jail provided Chiree Harley with all appropriate and necessary medical treatment for her and her unborn child.” He did not respond to questions about whether Harley was provided specialized obstetric care.

‘I Trusted Those People’

In states like Idaho, Mississippi, and Louisiana that installed near-total abortion bans after the Supreme Court eliminated the constitutional right to abortion in 2022, some patients might have to wait until no fetal cardiac activity is detected before they can get care, said Kari White, the executive and scientific director of Resound Research for Reproductive Health.

White co-authored a that documented 50 cases in which pregnancy care deviated from the standard because of abortion restrictions even outside of jails and prisons. Health care providers who worry about running afoul of strict laws might tell patients to go home and wait until their situations worsen.

“Obviously, it’s much trickier for people who are in jail or in prison, because they are not going to necessarily be able to leave again,” she said.

Advocates argue that boosting oversight and standards is a start, but that states need to find other ways to manage pregnant women who get caught in the justice system.

For many pregnant people, even a short stay in jail can cause lasting trauma and interrupt crucial prenatal care.

Collier remembers being in “disbelief” when she was first arrested but said she was not “distraught.”

“I figured I would be taken care of, that nothing bad was gonna happen to me,” she said. As it became clear that she wouldn’t get care, she grew distressed.

After her miscarriage, Collier saw a mental health specialist and started medication to treat depression. She hasn’t returned to her studies, she said.

“I trusted those people,” Collier said about the jail staff. “The whole experience really messed my head up.”

Ä¢¹½Ó°Ôº Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Ä¢¹½Ó°Ôºâ€”an independent source of health policy research, polling, and journalism. Learn more about .

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When Garner entered the gates at Louisiana State Penitentiary in Angola, Louisiana, he didn’t know what to expect. The maximum security facility has been dubbed “America’s Bloodiest Prison” and its brutal conditions have made headlines for decades.

“Sometimes when you’re in a dark place, you find out who you really are and what you wish you could be,” Garner said. “Even in darkness, I could be a light.”

It wasn’t until five years later that Garner would get his chance to show everyone he wasn’t the hardened criminal they thought he was. When the prison warden, Burl Cain, decided to start the nation’s first prison hospice program, Garner volunteered.

In helping dying inmates, Garner believed he could claw back some meaning to the life he had nearly squandered in the heat of the moment. For the next 25 years, he cared for his fellow inmates, prisoners in need of help and compassion at the end of their lives.

The Angola program started by Cain, with the help of Garner and others, has since become a model. Today at least 75 of the more than 1,200 state and federal penal institutions nationwide have implemented formal hospice programs. Yet as America’s prison population ages, more inmates are dying behind bars of natural causes and few prisons have been able to replicate Angola’s approach.

Garner hopes to change that. But first he had to redeem himself.

‘Life Means Life’

Garner, the son of a longshoreman, was born and raised in New Orleans as one of seven kids who kept their mother busy at home. He attended Catholic primary school and played football at Booker T. Washington High School. After graduating, Garner worked for a garbage collection company, then for an ice cream manufacturer, testing deliveries of milk to make sure they hadn’t been watered down.

None of that experience would help him at Angola, where violence seemed to be everywhere. Garner remembered the endless stream of ambulances rolling through the prison gates.

“All day long: Somebody has gotten stabbed, somebody had gotten into a bad fight, blood everywhere,” he said.

Cain arrived at Angola in 1995, three years into Garner’s life sentence. In 1997, the warden came across a newspaper article about a hospice program in Baton Rouge, the state capital.

“I realized that if we did hospice, I wouldn’t have to do that rush at the end of life. We wouldn’t have to put them in an ambulance and send them to the hospital,” Cain said. “We could let them die in peace and not have to do all that.”

At first, the prison’s medical staff objected, worried about the cost. But Cain put his foot down. He hired a hospice nurse to run the program, and inmates would provide the day-to-day care at no cost.

Cain sought volunteers and funding from what he called the prison’s “clubs and organizations” — the Aryan Brotherhood, the Black Panthers, as well as the religious congregations within the prison walls. “All of y’all one day are going to be in hospice,” he said he told them.

It was no exaggeration. In Louisiana, as the saying goes, life means life, with no chance of parole. And at that time, 85% of those sent to Angola would die there, according to Cain and others.

“We buried more people a year than we released out the front gate,” Cain said.

Many serving life sentences no longer had family outside the prison walls, and for those who did, their families often could not afford to pay for a funeral or burial spot. So, the prison would bury the bodies at Angola. When the first cemetery was filled, the prison established another.

Initially, inmates were buried in cardboard boxes. But during one funeral, the body fell out of the box onto the ground. Cain vowed that would never happen again and instructed inmates working in carpentry to learn to make wooden caskets. The prison then provided caskets for any inmate in Louisiana whose body was not claimed by their family. The late Rev. Billy Graham and his wife were buried in two made at Angola.

Cain saw the hospice program as part of his approach of rehabilitation through morality and Christian principles. Cain started a seminary program at Angola, had the prisoners build several churches on its grounds, and considered hospice “the icing on the cake.”

The Early Days

Garner had never heard of hospice.

He was among the first 40 volunteers at the prison, hand-picked for their clean disciplinary records and trained by two social workers from a New Orleans hospital in 1998.

Isolation cells were remade to serve as hospice rooms. The volunteers repainted the walls and draped curtains to hide the wire mesh covering the windows. They brought in nightstands and tables, TVs, and air conditioning.

Soon, it became clear the prison would have to change its rules to accommodate hospice. Before the program existed, inmates weren’t allowed to touch each other. They couldn’t even assist someone out of a wheelchair.

“They would actually push them into a room and wait on the nurse or doctor or somebody else to assist them,” Garner said. “They would die alone. They had nobody to talk to them, other than nurses and doctors making their rounds. They really didn’t have nobody that they could relate to.”

The volunteers were issued hospice T-shirts that allowed them free movement through the prison. Cain made it clear to the correctional officers and the staff that if someone was wearing that shirt, it was like hearing directly from the warden.

“He had to rewrite policies so everything that a hospice program can do in society, that program can do as well inside corrections,” Garner said.

The primary rule of the hospice program was that no one would die alone. When death was imminent, the hospice volunteers conducted a vigil round-the-clock.

The program used medications, including opioids, for the palliative care of patients, though the inmate volunteers were not allowed to administer them.

The first hospice patient Garner saw die was a man the prisoners called Baby. Standing just 4-foot-5, he was sought out by other inmates for his self-taught legal expertise. In 1998, as Baby was dying from cirrhosis, a disease of the liver, inmates rushed in to get his advice one last time.

“So many people wanted to see him, we just didn’t have enough room to take everybody in,” Garner said. “We used to have to do increments of 10 guys or whatever.”

Baby had taken care of everybody else. Now it was their time to take care of him.

Most of the hospice volunteers were serving life sentences, and many, like Garner, had taken someone’s life to get there. But holding a man’s hand as he took his last breath provided a new perspective.

“We all don’t know much about death, only what we see through the eyes of somebody who was going through that transition,” Garner said. “It was new to me, because I didn’t understand it in its entirety until I got into the program.”

The hospice volunteers became the conduit for inmates to get messages to their dying friends.

But more importantly, they functioned as confidants, giving dying inmates a last chance to get something off their chest.

“You become their hands, you become their eyes, you become their feet, you become their thinking sometimes,” Garner said. “They’re so vulnerable to where you actually have to be so mindful and careful to carry out their will.”

In a place where people prey on weakness, hospice volunteers shared in each patient’s vulnerability. Instead of assaulting, they assisted. Instead of sowing conflict, they spread peace.

“Just a touch makes a big difference, when a person can’t see or a person can’t hear,” Garner said.

‘What About Quilting?’

As the years passed, hospice deaths became more prevalent, with two to three inmates dying a week. The prison population was graying, and not just at Angola. According to , from 1991 to 2021, the percentage of state and federal inmates 55 and older grew from 3% to 15%. And in 2020, 30% of those serving life sentences were at least 55 years old.

Throughout the 2000s, the Angola hospice saw increasing deaths from cancer, hepatitis C, and AIDS. But mostly, the patients’ bodies were wearing out. Most had come from low-income backgrounds and arrived at Angola in less-than-optimal health. Prison took a further toll, accelerating aging and exacerbating chronic conditions.

The hospice volunteers tried to grant the dying inmates’ often modest last requests: fresh fruit, a peanut butter and jelly sandwich, some potato chips.

“A bag of chips, to people in society, it’s like, ‘Oh man, that ain’t it,’” Garner said. “But to somebody that has a taste for it or for somebody that’s about to pass away, their wanting is everything.”

But those wishes cost money. In 2000, the prison volunteers were brainstorming ways to make the program self-sufficient.

“What about quilting?” suggested Tanya Tillman, the hospice nurse.

The room fell silent, Garner recalled. The volunteers looked around nervously.

“That was not something that a male inmate wanted to hear,” Garner said.

But the other “clubs and organizations,” as Cain called the inmate groups, were also raising money through fundraisers. They needed something that would stand out, something they would have no competition over.

“And so we voted,” Garner said. “Quilting it was.”

None of the men had quilted before. Some women came to teach them the basics, but mostly they learned through trial and error.

“I just put a sewing machine in front of me,” Garner said. “I knew all the do’s and don’ts, but I didn’t know how to take and cut fabric, and put fabric together, and make it make sense.”

They auctioned off their first quilt at the , a biannual event in which prisoners compete in traditional rodeo events. It attracts people from all over the world.

At one point, Garner and his team were making 125 or more quilts a year: throws, kings, and queens.

“Within five years, we was on the front cover of Minnesota Alumni magazine,” Garner said, referencing the University of Minnesota Alumni Association’s publication. “In 2007, we were on another front cover, Imagine Louisiana magazine, and then in 10 years, we was in documentaries with Oprah Winfrey,” Garner said.

The Oprah Winfrey Network profiled the prison hospice program in 2011 in a documentary titled “Serving Life.”

Quilts made in Angola now hang in , the Smithsonian Institution’s in Washington, D.C., and the building in Alexandria, Virginia.

One of the first quilts Garner made was a passage quilt, used instead of a plain white sheet to cover bodies being transported to the morgue. The quilt showed the clouds opening and angels receiving the inmate into heaven. It was adorned with the words, “I’m free, no more chains holding me.” Garner made another quilt to drape over the casket during funeral processions.

The program used the proceeds from the sale of other quilts to stock a cabinet with food and other sundries the hospice patients might need. If a patient’s family did not have the money to travel to Louisiana to see their loved one in his final days, the program would pay for their airline tickets. The family could stay overnight in the patient’s room, something that was unheard of in a maximum security prison.

The hospice program broke a lot of prison norms, and seemingly anything was on the table. When one hospice patient’s dying wish was to go fishing, the volunteers got the warden’s approval and brought a group of inmates with him.

The Mississippi River surrounds the Angola area on three sides, and the staff baited a fishing hole for days before the excursion so fish would be biting when the dying man arrived.

The fishing excursion became an annual event.

“You see the smile on their faces catching those fish,” Cain said. “They forgot all about that they were terminal.”

He added, “It teaches us to normalize our prisons and quit making them abnormal, bad places, and make it make people think they’re bad people. Hospice is the best example of all, to teach you to give back and then you will heal, and you won’t have more victims when you get out of prison.”

A Change in Prison Culture

Soon the impact of hospice was being felt well beyond the volunteers and their patients.

“It’s of their facilities. It changed the general population,” said Jamey Boudreaux, the executive director of the . “The general population sees people caring and it’s kind of contagious.”

When Boudreaux was hired in 1998, his first task from the board of directors was to shut down the hospice at Angola.

“They’re calling something hospice,” he recalled the board telling him, “and we can just see that there’s going to be some sort of big scandal and hospice is going to get a bad name.”

He called the prison and Cain invited him to come see the hospice program in person. Boudreaux, who had never been in a prison before, sat through a two-hour meeting with hospice volunteers and correctional officers.

He didn’t shut it down. Instead, he continued to attend monthly meetings at the prison for the next five years. Eventually, the administrators asked him if he’d feel comfortable being there alone with the volunteers, so they could speak more freely.

“I got to know these guys and they were genuinely committed to this whole notion of taking care of people at the end of life,” he said. “For some of them, it was a way to find redemption. For others, it was an affirmation that, ‘I don’t deserve to be in this place. And this gives me a very safe place to spend my time in prison.’”

The concept of prison hospice began to spread. In 2006, and again in 2012, Angola hosted a prison hospice conference. Now, five of the eight state prison facilities in Louisiana have inmate volunteer hospice programs. Nationwide, about 75 to 80 hospice programs operate behind bars.

“Most are pretty basic,” said Cordt Kassner, a consultant with in Colorado Springs, Colorado. “Angola is head and shoulders the model; the best one, period.”

Regaining Freedom

Between caring for patients, sewing quilts, and working in the prison library, Garner had little time for anything else, though he continued to push for his case to be reviewed to earn his freedom.

Then, during the covid-19 pandemic, the quilters were asked to sew masks for the prison. The prison set up shifts so prisoners could maximize use of the sewing machines, keeping them running 24 hours a day. Masks were shipped to other prisons as well. Garner estimated he made 25,000 masks.

“I actually had to take time away from my work, from trying to get out of that place, working legal work and stuff,” Garner said.

Finally, in 2021, his case was reviewed by the Orleans Parish District Attorney’s Civil Rights Division. A judge agreed with the district attorney that in receiving life sentences at Angola, Garner and his brother had been oversentenced. They offered the brothers a deal: They could plead guilty to the lesser charge of manslaughter and be released for time served.

Garner had to think about it. His lawyers told him he likely had a good case to sue and be compensated for the many years he had spent in prison. But if he took the deal, he couldn’t sue.

“I could fight it or gain my freedom,” he said.

His family wanted the brothers home. Garner had lost his mother, his father, two brothers, and an aunt while behind bars. He and his brother opted to forgo any money that might come their way and secured their release.

“Steven Garner came in as a horrible criminal,” Cain said. “But he left us a wonderful man.”

Most of Garner’s immediate family had moved to the Colorado Springs area after being displaced by Hurricane Katrina, and in January 2022, after serving 31 years in prison, he joined them.

Spreading the Message

Quilting is an art of putting scraps of fabric together, making everything fit coherently. Now out of prison, Garner had to find a way to make all the pieces of his life fit together as well. He found a job at a warehouse, rented a home near his family, and bought himself a car.

At his prison job, he made 20 cents an hour — $8 a week, $32 a month — that he used to buy soap and deodorant. It’s a strange feeling today, he said, to be able to go into a store and buy something that costs more than $32.

Now 51, he has missed the prime years of his adult life. But rather than trying to make up for lost time in some grand hedonistic rush, Garner went back to what had saved him. He started a consulting business to help prisons implement hospice programs.

Over the past two years, he has delivered speeches at state hospice association conferences, and last year he spoke at a meeting of the Colorado Bar Association.

For many hospice veterans, prison hospice reminds them of the initial days of hospice, when it was primarily a nonprofit entity, run by people called to serve others.

“You would be hard-pressed to find a hospice provider that’s willing to support hospice in correctional facilities,” said Kim Huffington, chief nursing officer at Sangre de Cristo Community Care, a hospice based in Pueblo, Colorado. “Hospice as an industry has undergone a lot of change in the last 10 years and there’s a lot more for-profit hospices than there used to be.”

Yet talking to Garner, she said, has reignited her passion for the field.

“In many situations, we tend to dehumanize what we don’t understand or have experience with,” Huffington said. “The way he can make you see what he’s experienced through his eyes is something that I take away from every conversation with him.”

In September, Garner went back to prison, this time at the behest of the Colorado Department of Corrections, which wanted his advice on how to restart a defunct hospice program at Colorado Territorial Correctional Facility in Cañon City.

It was a surreal experience entering a prison again, dropping his keys in a little basket at the security screening, knowing he’d get them back shortly.

“It was really just another experience in my life,” Garner reflected, “that I can come and go, rather than come and stay.”

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At least 59 prisoners died of overdoses last year, according to a Ä¢¹½Ó°Ôº Health News analysis of data the California Department of Corrections and Rehabilitation is required to report under a new state law. That’s more than double the number who died of overdoses in each of 2020 (23) and 2021 (24).

Prison officials would not provide the number of overdose deaths in 2022, saying they are still being analyzed for a report to be released later this year. But attorneys representing prisoners said they believe there were substantially more fatal overdoses in 2022 than in the previous two years.

The new numbers are a big setback for state officials, who poured resources into overdose prevention efforts after a record 64 overdose deaths in 2019 gave California prisons the highest drug overdose death rate of any state correctional system in the United States.

With nearly 94,000 state prisoners, California is one of the nation’s largest providers of medication-assisted drug treatment. The prisoners’ attorneys still support California’s , saying there would be even more deaths without it.

“Fentanyl. That’s I think probably the main cause from what I hear,” said Don Specter, a lead attorney in the major class-action lawsuit over poor medical care of California prisoners, referring to the synthetic opioid at the heart of the nation’s overdose crisis. “Nothing else has really changed too much. It’s very pervasive.”

With a lower prison population than in previous years, California’s 2023 numbers represent a record high overdose death rate of at least 62 per 100,000 prisoners — and the numbers are likely to rise further as the cause of death is determined in some cases.

“National data has shown an alarming increase of overdose deaths across the country, largely driven by synthetic opioids (primarily fentanyl),” Ike Dodson, a spokesperson for California Correctional Health Care Services, said in an email. He added that prison officials “continue to evaluate substance use disorder treatment to improve the safety and well-being of all who live or work in a state correctional facility, including plans to broadly expand access to Narcan,” an overdose reversal device.

Until now, California’s increasingly comprehensive drug intervention program had been an apparent .

In January 2020, when the prison population was about 124,000, the state began using drugs like buprenorphine, naltrexone, and methadone to lessen drug users’ cravings and the crash of withdrawal symptoms while helping them stay away from dangerous opioids. The new program’s focus on medication-assisted treatment appeared to be working after deaths fell to 23 that year.

The medication-assisted treatment is one of five core components of the prison system’s approach: screening every arriving prisoner for substance abuse; use of medication where needed; therapy; supportive housing in prisons; and pre-release planning and post-release assistance. Officials say all five have now begun to varying degrees, at for the fiscal year starting July 1, 2024.

By 2021, the prisons’ reported overdose death rate fell to 25 per 100,000, less than half the rate before the program began and well below the overall national average.

There also was a nearly one-third drop in drug-related hospitalizations and emergency room visits among California prisoners receiving the medication-assisted treatment, researchers for the program said in a last year.

In promoting the approach, corrections experts California’s “immediate and significant” progress in reducing deaths, emergency hospitalizations, and drug abuse-related infections. While the use of medications to help keep prisoners from using opioids is rapidly expanding, it remains underused nationally in other prison and jail systems, the report said.

But last year’s preliminary overdose death toll in the state’s prisons was close to the record numbers of 2018 and 2019. Overdoses likely caused 11 deaths in October, according to attorneys representing prisoners — the most they had seen in a month.

Drug-related hospitalizations also have seen a more recent surge, attorneys representing prisoners said, citing the state’s data in a December court filing.

Efforts to crack down on the smuggling of drugs and other contraband into prisons have had limited effect.

Corrections spokesperson Alia Cruz said the department favors a “” that couples prison security with deterring smuggling and disrupting gangs and other drug distributors.

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The 55-year-old struggles with depression, addiction, and suicidal thoughts. He worried a judge would terminate him from a special diversion program meant to keep people with mental illness from being incarcerated. He was failing to keep up with the program’s onerous work and community service requirements.

“I’m kind of scared. I feel kind of defeated,” Brown said.

Last year, Brown threatened to take his life with a gun and his family called 911 seeking help, he said. The police arrived, and Brown was arrested and charged with a felony of firearm possession.

After months in jail, Brown was offered access to the Health Empowerment Linkage and Possibilities, or HELP, Court. If he pleaded guilty, he’d be connected to services and avoid prison time. But if he didn’t complete the program, he’d possibly face incarceration.

“It’s almost like coercion,” Brown said. “‘Here, sign these papers and get out of jail.’ I feel like I could have been dealt with a lot better.”

Advocates, attorneys, clinicians, and researchers said courts such as the one Brown is navigating can struggle to live up to their promise. The diversion programs, they said, are often expensive and resource-intensive, and serve fewer than 1% of the more than 2 million people who have a serious mental illness and are booked into U.S. jails each year.

People can feel pressured to take plea deals and enter the courts, seeing the programs as the only route to get care or avoid prison time. The courts are selective, due in part to political pressures on elected judges and prosecutors. Participants must often meet strict requirements that critics say aren’t treatment-focused, such as regular hearings and drug screenings.

And there is a lack of conclusive evidence on whether the courts help participants long-term. Some legal experts, like Lea Johnston, a professor of law at the University of Florida, worry the programs distract from more meaningful investments in mental health resources.

Jails and prisons are not the place for individuals with mental disorders, she said. “But I’m also not sure that mental health court is the solution.”

The country’s was established in Broward County, Florida, in 1997, “as a way to promote recovery and mental health wellness and avoid criminalizing mental health problems.” The model was replicated with millions in funding from such federal agencies as the and the .

More than 650 adult and juvenile mental health courts were operational as of 2022, according to the . There’s no set way to run them. Generally, participants receive treatment plans and get linked to services. Judges and mental health clinicians oversee their progress.

Researchers from the center found little evidence that the courts improve participants’ mental health or keep them out of the criminal justice system. “Few studies … assess longer-term impacts” of the programs “beyond one year after program exit,” said a 2022 policy brief on mental health courts.

The courts work best when paired with investments in services such as clinical treatment, recovery programs, and housing and employment opportunities, said Kristen DeVall, the center’s co-director.

“If all of these other supports aren’t invested in, then it’s kind of a wash,” she said.

The courts should be seen as “one intervention in that larger system,” DeVall said, not “the only resource to serve folks with mental health needs” who get caught up in the criminal justice system.

Resource limitations can also increase the pressures to apply for mental health court programs, said Lisa M. Wayne, executive director of the National Association of Criminal Defense Lawyers. People seeking help might not feel they have alternatives.

“It’s not going to be people who can afford mental health intervention. It’s poor people, marginalized folks,” she said.

Other court skeptics wonder about the larger costs of the programs.

In of a mental health court in Pennsylvania, Johnston and a University of Florida colleague found participants were sentenced to longer time under government supervision than if they’d gone through the regular criminal justice system.

“The bigger problem is they’re taking attention away from more important solutions that we should be investing in, like community mental health care,” Johnston said.

When Melissa Vergara’s oldest son, Mychael Difrancisco, was arrested on felony gun charges in Queens in May 2021, she thought he would be an ideal candidate for the New York City borough’s mental health court because of his diagnosis of autism spectrum disorder and other behavioral health conditions.

She estimated she spent tens of thousands of dollars to prepare Difrancisco’s case for consideration. Meanwhile, her son sat in jail on Rikers Island, where she said he was assaulted multiple times and had to get half a finger amputated after it was caught in a cell door.

In the end, his case was denied diversion into mental health court. Difrancisco, 22, is serving a prison sentence that could be as long as four years and six months.

“There’s no real urgency to help people with mental health struggles,” Vergara said.

Critics worry such high bars to entry can lead the programs to exclude people who could benefit the most. Some courts don’t allow those accused of violent or sexual crimes to participate. Prosecutors and judges can face pressure from constituents that may lead them to block individuals accused of high-profile offenses.

And judges often aren’t trained to make decisions about participants’ care, said Raji Edayathumangalam, senior policy social worker with New York County Defender Services.

“It’s inappropriate,” she said. “We’re all licensed to practice in our different professions for a reason. I can’t show up to do a hernia operation just because I read about it or sat next to a hernia surgeon.”

Mental health courts can be overly focused on requirements such as drug testing, medication compliance, and completing workbook assignments, rather than progress toward recovery and clinical improvement, Edayathumangalam said.

Completing the programs can leave some participants with clean criminal records. But failing to meet a program’s requirements can trigger penalties — including incarceration.

During a recent hearing in the Clayton County Behavioral Health Accountability Court in suburban Atlanta, one woman left the courtroom in tears when Judge Shana Rooks Malone ordered her to report to jail for a seven-day stay for “being dishonest” about whether she was taking court-required medication.

It was her sixth infraction in the program — previous consequences included written assignments and “bench duty,” in which participants must sit and think about their participation in the program.

“I don’t like to incarcerate,” Malone said. “That particular participant has had some challenges. I’m rooting for her. But all the smaller penalties haven’t worked.”

Still, other participants praised Malone and her program. And, in general, some say such diversion programs provide a much-needed lifeline.

Michael Hobby, 32, of Gainesville was addicted to heroin and fentanyl when he was arrested for drug possession in August 2021. After entry into the HELP Court program, he got sober, started taking medication for anxiety and depression, and built a stable life.

“I didn’t know where to reach out for help,” he said. “I got put in handcuffs, and it saved my life.”

Even as Donald Brown awaited his fate, he said he had started taking medication to manage his depression and has stayed sober because of HELP Court.

“I’ve learned a new way of life. Instead of getting high, I’m learning to feel things now,” he said.

Brown avoided jail that early December day. A hearing to decide his fate could happen in the next few weeks. But even if he’s allowed to remain in the program, Brown said, he’s worried it’s only a matter of time before he falls out of compliance.

“To try to improve myself and get locked up for it is just a kick in the gut,” he said. “I tried really hard.”

Ä¢¹½Ó°Ôº Health News senior correspondent Fred Clasen-Kelly contributed to this report.

Ä¢¹½Ó°Ôº Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Ä¢¹½Ó°Ôºâ€”an independent source of health policy research, polling, and journalism. Learn more about .

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This story can be republished for free (details).